Put your knowledge and skills to the test with the case of Mr. C, a 61 year old man, who presents to clinic for follow-up on his antipsychotic medications that are used to manage psychosis and depression. He currently uses chlorpromazine 100mg/day and has had no psychotic symptoms in the last 3 years.

In terms of his psychiatric history, Mr. C first began to experience auditory and visual hallucinations at age 48, as well as a decline in cognition that led to his retirement from employment shortly thereafter. He has had 3 inpatient psychiatric admissions, and has continued to be treated with antipsychotics as discontinuation often leads to relapse of his psychosis.

While Mr. C has a history of aortic regurgitation, CHF, HTN, and sensorineural hearing loss, he also describes a history of cocaine abuse from 21-45. More interestingly, he also reveals a diagnosis of syphilis at 48yo, which went untreated for many months until he was diagnosed with neurosyphilis (tertiary syphilis) after developing abnormal gait, blurred vision, and general weakness.

Do you think Mr. C's psychiatric symptoms are related to his diagnosis of neurosyphilis? What tests would you order? What would you advise him on further management/treatment?

Health Canada announced early last week that they have approved a new ‪‎antipsychotic‬ medication for the treatment of ‪‎schizophrenia‬ in adults.

The medication is called Invega Trinza (aka paliperidone palmitate), a new version of the drug Invega Sustenna, which has already been out on the market for some time. Psychiatrists are hopeful regarding the impact Invega Trinza may have on the care of their patients and specifically their medication compliance and risk of relapse, as it is an injection that need only be administered four times a year, rather than on a monthly schedule in its old form.

"Adherence to medication is often a challenge for Canadians living with schizophrenia, with not taking medication as prescribed as the most common cause of relapse. Studies have shown that within the first five years of treatment, up to 80 per cent of people with schizophrenia had experienced one or more relapses. Each relapse can result in a reduced response to treatment, putting continued symptom control even further out of reach.

"Relapse prevention is a critical part of disease management and recovery-focused care for people living with schizophrenia," says Dr. Philip Tibbo, Director, Nova Scotia Early Psychosis Program in Halifax. "The unique dosing of INVEGA TRINZA can offer patients long-term symptom control. This could help to significantly reduce the risk of relapse over time." For more information about this new medication, check out the links below:

As a follow-up to last week's blog post about the increasing use of antipsychotics to manage behavioural and psychological symptoms of dementia (BPSD) in long-term care facilities, this week's post highlight's one nursing home's efforts to counteract this trend. Pathstone Living, a nursing home in Mannkato, Minnesota, has successfully altered their approach to managing BPSD from pharmacological to behavioural and environmental interventions. "A few years ago, antipsychotics were used frequently at Pathstone. 'We saw these as medications that were supposed to help the patient and, of course, we gave them to them with the feeling that we were doing good', says Shelley Matthes, a registered nurse who is head of quality assurance for the nonprofit Ecumen, which runs Pathstone and about a dozen other nursing facilities in Minnesota. Our goal, says Matthes, was to reduce our antipsychotic use by 20 percent. And in the first year we reduced it by 97 percent".

National headlines in recent years have highlighted the staggering rates in which antipsychotics are prescribed to frail elderly living in long-term care facilities for the management of challenging behaviours, such as agitation and aggression, even though these drugs are not approved for use in such circumstances and have been associated with increased risk of death in this population. The results of a new study published in JAMA this month indicate that atypical antipsychotics can further harm elderly by increasing their risk of falls and fractures. "Adults ages 65 and older who received a new prescription [for an atypical antipsychotic] had a 53% increased risk of falling and a 50% increased risk of non vertebral osteoporotic fracture. These findings call into question the widespread off-label use of atypical antipsychotic medications and support increasing evidence of safety concerns regarding their use in older adults". To read more about the research findings, visit http://www.medpagetoday.com/Neurology/GeneralNeurology/49529

There has been an alarming increase in the number of off-label prescriptions for Seroquel, an antipsychotic drug, for conditions not approved by Health Canada. The number of prescriptions for Seroquel, a drug only approved in Canada for treatment of bipolar disorder and schizophrenia, has nearly doubled between 2008 and 2013. Many doctors are prescribing the drug as a sleep aid.

However, Health Canada says some of Seroquel's side effects can be fatal and include diabetes, hyperglycemia, constipation and intestinal obstruction, and complications from blood clots.

Health Canada says it monitors safety issues associated with the use of health products, including psychotropic drugs such as Seroquel, but adds the issue of off-label prescriptions falls under the "practice of medicine" and is provincially regulated.

NDP health critic Libby Davies says that when it comes to off-label prescribing, the federal government is "sweeping it under the carpet." Davies says the New Democrats offered amendments to the newly passed Bill C-17 — or Vanessa's Law — which included improvements to transparency and prescribing practices for off-label use, but they were turned down by the federal government.Read more here:http://www.insidehalton.com/news-story/4913421-off-label-prescribing-raises-concern/